Cauda equina syndrome due to large B-cell lymphoma: a case report

Excerpt

A 47-year-old Caucasian man presented in August 2014 with a 4-month history of low back pain and progressive bilateral lower muscle weakness. In April and July 2014, two MRI scans of the spine were normal. In August 2014, he developed increasing low back pain with radiation to his thighs followed by numbness of his perianal region, buttocks and posterior thighs, with urinary retention and faecal incontinence. Moreover, he progressively developed ascending bilateral leg weakness. On examination, there were signs of a cauda equina syndrome. The weakness initially affected the muscles supplied by L5–S1 roots, with sensory disturbance in an S2–S5 distribution, but this rapidly progressed to a complete paraplegia with absent sensation to all modalities from L2 downwards. His legs were flaccid and areflexic. The pain became extremely difficult to control, and thus, he was treated with 3 days of 500 mg intravenous methylprednisolone followed by oral prednisolone 40 mg. A MRI scan of the spine detected an abnormal mass in the cauda equina (Fig. 1a, b). He had raised inflammatory markers (erythrocyte sedimentation rate 65 mm per first hour (<15) and serum C reactive protein of 240 mg/L (<10)). His serum lactate dehydrogenase was markedly elevated at 1847 IU/L (266–500 IU/L). Cerebrospinal fluid (CSF) examination showed raised protein 174 mg/dL and glucose was 53 mg/dL. A biopsy of the lumbosacral nerve roots disclosed a large B-cell lymphoma (Fig. 1c, d). Cytogenetic abnormalities of the lymphoma cells in CSF were not found. Extensive search for extraneural malignancy including cranial, spinal, chest and abdominal CT and MRI scans was all negative. Whole-body PET demonstrated hypermetabolism corresponding to MRI lesions. Because the patient’s clinical symptoms progressed rapidly, he was immediately treated with intrathecal chemotherapy with 12 mg of methotrexate, 20 mg of cytarabine and rituximab 830 mg. However, 2 months after the diagnosis, the patient died in November 2014.

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